Wag & Company

Referral Made By

Date of referral *

Referral contact name *

Referral Organisation

Organisation Type *

Organisation *

Department or Team

Organisation postal address *

Address first line *

Address second line

Postcode *

Town *

Referral Contact Details

Email *

Re-enter Email address*

Work telephone *

Mobile telephone

Emergency Contact

Emergency contact name *

Emergency contact mobile/daytime number

Emergency contact email

Emergency contact notes

Visitee Details

Title *

First name *

Last name *

How does he/she prefer to be addressed? *

Gender *

Date of birth * Age:

Status *

If applicable, how long have they been living alone?

Home address *

Address first Line *

Address second line

Postcode *

Town *

Please check and confirm that the address has been input correctly *

Type of accommodation *

Is this their own home? *

If not please provide details i.e. sheltered accommodation or assisted living or living with family and contact details for the primary home owner

Is there a working landline at the property? *

If so please include the telephone number

Is there mobile telephone signal at the property? *

Parking Advice: Is there a car parking space, a drive or is there on street parking, please provide details *

What type of dogs has he/she owned in the past? *

When did they lose their last dog? *

Are there, or have there recently been, any other pets in the property, eg a cat *

If so can you please describe the pet and confirm if applicable that they do not have fleas and receive veterinary recommended flea treatments at the required intervals

Does he/she have any health or mobility limitations we should know about? *

If so please provide details

Does he/she have any memory or judgement loss? *

If so how does that affect them in practice?

In your opinion would you judge he/she to have capacity for consent for the use of photographs for instance? *

Please provide the details of the risk assessment that has been carried out to enable lone working in these circumstances ie at these premises and with this person. *

Please explain in full the reasons for the referral and the desired outcomes. *

Could anyone else - a person or an organisation (eg carers) - be in the house when we visit? *

If so please provide full details including the relationship to the person we are visiting or if another organisation please provide the name of the agency and the contact telephone number

Is there potential for another dog (belonging to a relative or friend) to be visiting at the same time *

If so please provide likely visiting days and times

Is there any day or time where our visits would not be possible? *

If so please provide details

Does he or she have any particular requirements or preferences? e.g. male or female visitor, specific dog breed/type? *

If so please provide details

Is there any other useful information about the person or the premises our special befriending team should be aware of? *

If so please provide details